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H1N1 Vaccine Administration Billing Q & As

October 20, 2009 5:20 PM ET

The purpose of this Q&A is to provide guidance about the circumstances under which providers may bill insurance or charge patients when federal funds for H1N1 vaccination are being used. Receipt of federal Public Health Emergency Response (PHER) funding does not necessarily prevent a provider from billing insurance. The primary purpose of this guidance is to help ensure that duplicate payments are not made for the same service provided to the same patient. Federal funding recipients are subject to audit requirements to ensure that federal funds are spent consistent with applicable law.

NOTE: 2009 H1N1 influenza vaccine and ancillary supplies (syringes, needles, sharps containers, and alcohol swabs) have been purchased by the federal government and provided free of charge to all providers participating in this voluntary vaccination effort. Under the terms of the provider agreement, providers are not permitted to charge for the 2009 H1N1 vaccine itself.

This document does not provide legal advice. You should consult the primary public health counsel for your jurisdiction for any needed legal advice.

1: What is the definition of a "public health clinic"?

For the purpose of this document, a "public health clinic" is a clinic that is conducted by, or on behalf of, a state or local health jurisdiction and that receives Public Health Emergency Response (PHER) implementation funds to administer H1N1 influenza vaccine. This may include a commercial community vaccinator (CCV) or other private provider that has a service contract or similar agreement with the public health entity. Vaccine administration could occur in a variety of settings such as hospitals, provider offices, schools, clinics, and any other setting where vaccine can be appropriately given.

The provider agreement that each H1N1 vaccine provider must sign in order to receive an allocation of H1N1 vaccine does not constitute an agreement for the provider to administer H1N1 vaccine on behalf of the public health department. Providers must enter into separate agreements with state or local jurisdictions in order to provide vaccine on behalf of those jurisdictions. "Public health clinics" are only those clinics in which such agreements have been entered into and for which providers are paid, in whole or in part, with PHER funds.

2: May providers charge patients a co-pay or other out-of-pocket charge in public health clinics or mass vaccination sites/clinics conducted on behalf of a public health entity?

Public health clinics and mass vaccination sites/clinics conducted on behalf of a public health entity should not charge patients a co-pay or other out-of-pocket charge, even if the patient’s health plan includes a co-pay for vaccine administration. Many public and private health plans will not require co-pays or other cost sharing for H1N1 vaccine administration.

3: May providers bill third party payers or insurers in public health clinics or mass vaccination sites/clinics conducted by, or on behalf of, a public health jurisdiction?

Providers may bill third party payers or insurers in public health clinics or mass vaccination sites/clinics conducted by, or on behalf of, a public health entity. Public health jurisdictions that do not currently have a billing system in place should not use PHER funds to develop billing systems.

4: May public health jurisdictions give PHER funds to private providers to offset the provider’s vaccine administration costs for vaccination of uninsured or under-insured persons?

A public health jurisdiction may give PHER funds to private providers to offset the costs of vaccine administration to the uninsured or under-insured population, provided that the jurisdiction has auditing or other accountability systems in place to track the funds transmitted and ensure they are used appropriately. Jurisdictions that do not have such systems in place should not use PHER funds to develop them.

5: If a private provider is given PHER funds to offset the costs of vaccinating uninsured or under-insured patients, may that provider charge a vaccine administration fee to insured patients?

Yes. Providers may collect copayments and other charges from patients who are insured in order to cover the costs of vaccine administration, if such charges are permitted by the insurer. However, providers should not charge uninsured or under-insured patients a vaccine administration fee if the provider has been given PHER funds specifically for vaccination of uninsured or under-insured patients.

If the provider has been given PHER funds to conduct a clinic on behalf of a state or local public health entity, as described above, the provider is not allowed to collect copayments or any other out-of-pocket charges from any patients, whether or not they are insured.

6: If a provider receives PHER funds to conduct a public health clinic, may that provider charge any patients for administration of H1N1 vaccine at any time?

Providers should not charge any patient who visits a clinic conducted on behalf of public health that is paid for entirely, or in part, by PHER funds. If the PHER funds are only for one clinic on a single day, the provider may charge on any other day, or for patients that are not seen at the PHER-funded clinic. For example, if there is a clinic at the provider site that is paid for with PHER funds, but patients are also being seen one-on-one at that site, the provider may charge for the one-on-one visits as long as those visits are not being paid for with PHER monies, but may not charge anyone seen in the public health clinic.

7: If PHER funds are used to pay the salary of a health department employee, may that employee assist with vaccination clinics in which patients are charged for administration of vaccine?

Yes. Employees hired with PHER dollars may assist with H1N1 vaccination in any setting.

8: What terms and conditions are required in contracts between private providers and public health jurisdictions?

CDC has not established federal requirements or terms and conditions to include in contracts or other agreements between state and local health jurisdictions and providers. Terms of contracts for public health clinics are at the discretion of the state or local health jurisdiction and the contracting provider to negotiate. However, contracts between private providers and public health departments must be consistent with the terms of the H1N1 provider agreement.

9: If a provider receives PHER funds to conduct a public health clinic, can patients with insurance coverage for H1N1 vaccine administration be vaccinated at that clinic?

Yes. PHER funds are intended to cover administration costs of vaccination regardless of insurance status. Providers may bill third-party payers or insurance plans in clinics conducted on behalf of public health if desired. Providers who receive PHER funds and who also bill insurance should ensure that duplicate payments are not received for the same service provided to the same patient.

10: May providers bill private third-party payers or insurers for H1N1 vaccine administration if the level of reimbursement provided by the private insurer is greater than the regional Medicare vaccine administration rate?

Yes. The H1N1 provider agreement states that the provider “may charge a fee for the administration of the vaccine to the patient, their health insurance plan, or other third party payer. The administration fee cannot exceed the regional Medicare vaccine administration fee.” This means that the provider may not request out-of-pocket payment from a patient that is greater than the amount that Medicare reimburses for influenza vaccine administration in that jurisdiction. “Charge” refers to collecting an out-of-pocket payment from the patient.

However, the provider agreement does not dictate the level of reimbursement for vaccine administration that is provided by an insurance plan or payer. Providers should bill payers and insurance plans at their regular agreed-upon rates, and may accept whatever level of reimbursement is provided by a plan or payer for H1N1 vaccine administration.

11. Are federally qualified health centers (FQHCs) or rural health clinics (RHCs) permitted to bill third party payers or insurers for administration of H1N1 vaccine?

Yes. FQHCs and RHCs should follow the same rules as other providers. If the FQHC or RHC has received PHER funds from a state or local health jurisdiction, that clinic may bill third-party payers or insurers for H1N1 vaccine administration, but may not collect copayments or out of pocket charges from patients, even on a sliding fee scale. If the FQHC or RHC has not received PHER funds to support H1N1 vaccine administration, it may bill or charge patients for vaccine administration costs (but not for the vaccine itself) as it usually does, when permitted by the insurer or third party payer. Like other public and private providers, FQHCs and RHCs providing H1N1 flu vaccine must abide by the terms of the H1N1 provider agreement.

12: May voluntary donations be collected from patients in public health clinics or mass vaccination sites/clinics conducted on behalf of a public health entity?

It is critical that perceived cost of vaccination not be a barrier to vaccination. Donations are acceptable only if it is clear that they are completely voluntary, and if they are collected after vaccination takes place. Public health clinics should ensure that any donations collected do not constitute duplicate payment for vaccines administered to patients in the clinics.

13: May providers bill health insurance plans that require a charge of $0.01 for the vaccine in order to process claims, even though it is not permissible to charge for H1N1 vaccine?

Yes. It is understood that billing software is complex and may require submission of a nominal fee for the vaccine in order to process claims. Providers may bill a charge of $.01 with the vaccine code. However, providers may not bill patients any fee for the vaccine, and should inform patients about the $.01 fee and that it may appear in their insurance statement.